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At Jaslok Hospital, we believe a liver transplant is a lifelong commitment for you and for us. We will stay involved with you and your family through the entire transplant process. We get to know you very well and recognize that preparing for and living with a transplant will affect your lifestyle in many ways. We will help you maintain and resume many of your activities and even become involved in new ones.

With state of the art infrastructure and the best surgeons, the hospital provides the most advanced and comprehensive transplant care in India.

Jaslok Hospital is recognized as a multi-disciplinary management centre with integrated specialties for liver.

We are committed to the time, effort, and resources required to make your transplant a success. Our definition of success extends far beyond the operating room. We will work with you to make your life after the transplant as successful as possible.

A few facts about liver transplantation:

1. Only cure for advanced stages of cirrhosis

2. Can be done by donation by a brain dead person or by a close relative with matching blood group

3. Done in time, it carries 80% success rate

4. Close follow up is essential after transplant

5. Life can be completely normal after transplant

Who needs a Liver Transplant?

According to international guidelines, any patient suffering from liver cirrhosis who is assessed to have a life expectancy of less than a year should be considered for a transplant. Severity of liver disease is graded from A to C. Usually all Grade C and most grade B patients are candidates for transplant. Any patient with any of the liver failure symptoms listed below should seek specialist opinion so that liver experts can assess whether a transplant or drug treatment is more suitable for them. In any case, the better the condition of the patient at the time of transplant, the better are the results of surgery. In patients who are critically ill in ICU, malnourished, have active infection, or other organ damage such as kidney impairment at the time of the operation, the results of transplantation are dismal. Therefore, timely transplant is of essence in obtaining good results. A timely transplant done on a patient who is in a reasonable condition, with a good donor liver has around 80% chance of success.
In most instances, the above causes initially result in Hepatitis which can usually be treated. However, if the offending factor is not removed or treated on time, cirrhosis develops and then it is usually too late to change the course of the disease.Symptoms of liver failure due to cirrhosis
• Black stool
• Blood vomiting
• Water in the abdomen (ascites)
• Drowsiness and mental confusion
• Excessive bleeding from minor wounds
• Jaundice
• Kidney dysfunction
• Excessive tiredness
• Low hemoglobin and other blood counts

Pre-transplant evaluation (Liver Transplant Assessment)

The liver specialist usually suggests this evaluation once he has diagnosed end-stage liver disease. Recipient evaluation is done in three phases and normally takes 5-7 days in hospital.
• To establish definite diagnosis, determine the severity of liver disease and the urgency of the transplant.
• To determine the fitness of the patient for a transplant. The other systems such as heart, lungs, kidneys, blood counts are tested and the presence of any infection is ruled out. The liver specialist then decides how successful the surgery is likely to be depending on the status of the patient and the cause and severity of liver disease.
• The final phase entails the psychological and mental preparation of the patient. The patient and the family are counselled about the procedure, hospital stay, the likely course after surgery, follow up and aftercare.

After evaluation, the patient is either placed on the waiting list for cadaveric donation, or, if there is a willing and blood group matched family donor available, he/she is evaluated for donation and a transplant is scheduled.
While on the cadaver waiting list, the patient follows up with the Transplant Team until a suitable liver becomes available. If the patient's condition shows signs of deteriorating, we normally suggest the family to consider living liver donation.

Getting admitted to the hospital for transplant

Living donor transplants are planned in advance, patients and donors are admitted to the hospital a day prior to surgery. Both donors and recipients must not eat or drink anything after midnight before the operation.

Deceased donor transplants are performed on emergency basis when a cadaveric liver is available. Patients are called to the hospital urgently; they undergo a rapid review and tests before surgery to ensure that they are healthy and ready for surgery. Patients should not eat or drink anything once they receive intimation for the transplant.

After the patients are admitted, the transplant team has a discussion about the quality of organ and
transplantation process and ask the patient to sign the consent form after complete understanding of the process. Patients should inform the transplant team about pre-existing health problems, current medicines and known drug allergies, to prevent any accidental use and interaction with transplant medicines. If patients develop new unexpected problems such as fever, if review tests show significant change compared to previous reports or if any new concerns or active problems are discovered, they might need treatment first and the transplant might have to be postponed.

The operation

The timings of donor and recipient surgeries are synchronized to ensure minimal ischemia (storage damage) to the liver. In deceased donor transplant, patients' surgery is started only after donor liver has been
examined and found satisfactory. The operation does not start immediately after the patient is taken to the operation theatre as it takes about 2 hours to prepare for the operation. Both donors and recipients undergo the operation under general anesthesia, where they are put to sleep, with no consciousness, pain, awareness or recollection of the operation. While under anesthesia, they are put on a ventilator and various lines /
catheters (arterial line, central line, endotracheal tube, urinary catheter, naso-gastric tube, etc) are used to accurately monitor various parameters and allow rapid administration of blood products, IV fluids and drugs. During the surgery, various blood and other tests are continuously performed for monitoring.

Donor operation

The living donor operation involves removal of a portion of the liver and may be done using different types of incisions or even with laparoscopy (keyhole) or robotic surgery. The choice of incision depends on donor's body habitus and findings during surgery. This decision is best made during surgery. The transplant surgeons always keep in mind the cosmetic results and safety while choosing an incision. The liver is split in two parts as planned pre-operatively. One of these parts is
removed along with the blood vessels and bile ducts going in and out of the lobe, leaving the other half in the donor with its blood vessels and bile ducts intact.The surgery lasts about 6-8 hours. In addition to the planned portion of the liver, the gall bladder is always removed because it is stuck to the under surface of the liver. A drain tube is kept in the abdomen to monitor any bleeding and the incision line is closed using very fine absorbable sutures or staples.

Recipient operation

The first step is to remove the entire cirrhotic liver (including gall bladder) to make space for the new liver. The cirrhotic liver is shrunken, stiff with multiple thin-walled blood vessels around it under high pressure and may be stuck to surrounding organs because of previous infection or surgery. This part of the operation is done slowly to minimise chances of bleeding. This is followed by transplantation of the new liver by joining (anastomoses) all blood vessels andallowing blood circulation through the liver. The liver starts working immediately. Bile ducts of the new liver may be joined with the patient's own bile duct or directly with the intestine. A drain tube is kept in the abdomen to monitor for any bleeding and the incision line is closed using staples. The recipient surgery generally takes 8-12 hours and about 5-10 units of blood and blood products are used, however, in difficult cases, it may be much longer with significantly more blood product requirement.

At the end of surgery, the donor is taken off the ventilator and shifted to the ICU for overnight observation the recipient is generally shifted to the ICU on a ventilator.

While the operation is going on, family members should stay in the waiting lounge. The transplant team will talk to them at the end of the surgery.

Post operative care & recovery after transplant
Recovery from liver transplantation depends on many factors including patients age, overall health, severity of liver disease, infections, secondary organ dysfunction or complications before or after the operation. Good understanding of the process, moral support and encouragement from family, a positive attitude and strong will-power are important in patients' recovery.

In the hospital

Donors wake up immediately after the surgery, although they might feel drowsy for a few hours. They are
able to get out of bed in 1-2 days and made to walk in 2-3 days. Various lines, catheters and drains are
removed as they recover. Generally, they can have liquid diet followed by normal diet in 2-5 days, shifted to the ward in 1-2 days and discharged in 5-7 days. Pain killers medicines are given depending on their pain threshold. Some patients prefer to take pain medicines before walking or any exercise that may trigger pain or just before going to sleep for a comfortable night. On discharge, they are generally given painkillers and vitamins. Most donors will have an uneventful recovery although some might have mild problems such as fever, loss of appetite, nausea or even vomiting because of slow bowel movement after surgery, which can be treated easily and resolves over time.

Patients (recipients) are kept on a ventilator overnight and it is removed when they are fully awake. Patients are closely monitored for any bleeding, infection or other complications. First 24-48 hours are critical and their condition and liver function are monitored by doing frequent blood tests. Various lines, catheters and drains are removed as they make progress / recover over 3-4 days. Patients are given liquid diet followed by normal diet in 2-5 days. In patients where the bile duct has been joined directly with the intestine, the naso-gastric tube may be kept longer and diet may be delayed. Patients are helped out of bed in 1-2 days; they participate in the physiotherapy program, walk in 4-5 days and gradually become more active. Patients should actively do incentive spirometry to prevent collapse of lungs, prevent lung infections and recover faster.

Patients should learn to support their incision with a pillow when coughing. Patients generally do not have a lot of abdominal pain after surgery although they may experience back and shoulder pain because of lying down on the operating table for a prolonged time. Patients are given pain medicines as per their need. Some patients may be confused, agitated or have mood changes because of the effect of sedatives or disturbance in sleep pattern after surgery, it generally resolves in a few days. Patients are shifted to the ward in 3-5 days and remain in hospital for about 10-15 days. At discharge, patients receive anti-rejection medicines, antibiotics and some other medicines.
In both donors and recipients, blood tests, ultrasound and chest x-ray are done regularly to monitor liver function and recovery as per standard protocol. Patients families are generally updated about their progress by the transplant team once a day or more often, if appropriate. While it is natural for patients and families to be anxious, questions for the transplant team should be asked during the counselling sessions or during ward rounds. Visiting hours and the number of visitors is restricted to prevent infections.
Discharge from the hospital

While the patient recovers from the operation, the family should take the opportunity to learn about precautions to be taken after discharge, understand the schedule for testing and follow-up appointments, become familiar with medicines, learn about the warning signs of potential problems and understand the mechanism to contact the liver transplant team around the clock in case of urgent problems. We have daily group counselling sessions for both the patients and the donors and the relatives where they are counselled by our post op coordinators, physiotherapists and the nutritionists, attending these sessions will help in discharge planning.

At the time of discharge, patients will get a discharge summary with detailed instructions about testing a on medication schedule, which should be discussed with the transplant coordinator. Patients also get a copy of the investigation chart, blood sugar and blood pressure monitoring chart, which they should be familiar with and learn how to fill.

After discharge, patients are required to undergo tests and visit post-transplant clinic every 5 – 7 days. They should therefore stay in the vicinity of the hospital for 4-6 weeks after discharge. The house where the patient would be staying should be prepared.

Infection prevention:

- The house should be thoroughly cleaned with disinfectants
- The accommodations should be close to hospital with available transportation 24hrs a day, there should not be too many stairs and the locality should be neat and clean.
- Patients are encouraged to walk and avoid using a wheel chair
- The number of visitors should be restricted for few weeks
- Patients should avoid meeting people who are ill and report any illnesses / fever / flu / cold / persistant cough / pain in abdomen / loose motions or transmissible infections or infectious diseases such as influenza, pneumonia, chicken pox, hepatitis etc.
- Patient should avoid contact with animals and birds to prevent infection.
- For the first 2 to 3 months, patients are advised to wear a mask and avoid crowded public places like malls, cinemas, restaurants, department stores, etc.After this patients can attend social events and live a normal life.

Personnel hygiene and wound care:

- Frequent handwashing with soap, especially before eating, should be practiced by all family members and hand-washing with antiseptic solution after using the bathroom.
- Oral hygiene should be maintained by brushing teeth daily rising mouth after eating
- Finger nails should be trimmed
- After discharge, dressing might need change 2-3 times a week.
- Few donors / patients may be discharged with a drain tube in the abdomen, which is removed few days after discharge.
- While one has wound dressings and grain bags, body should be cleaned with a wet towel only, fresh washed cloths should be worn daily.
- Once wound heals and the bags are removed, patients / donors can use water proof dressings and take normal bath before every dressing change.
- Donor stitches / staples are generally removed within 2-3 weeks and the recipients within 3-4 weeks, unless absorbable stitches are used which do not need removal.
- Once the staples are removed, incision should be kept clean & dry. Patients / donors can take a daily shower or normal bath.
- If the incision oozes some fluid or if the dressing nurse says that there is some infection in the wound, please insist that the nurse speaks to the transplant team immediately.
- The dressing nurses are trained and will evaluate the condition of wound, decide the frequency of dressing changes and timing of staples / stitches removal, in consultation with the doctor.

He is qualified Gastroenterologist at Jaslok Hospital since last 4 years. He has done fellowship in Hepatobilliary & liver transplantation. Presented many papers at national as well as international level and published articles in peer reviewed journals

Brief write up
Dr A S Soin is recognized all over the world over for his pioneering work in establishing liver transplantation in India. Dr Soin has performed more than 2500 living donor liver transplants in India, which is the highest in the country, and the second highest in the world. He and his team currently perform 22-25 live donor liver transplants every month with 95% success - results which are at par with the world's best centres. Apart from referrals from all over the country, he handles cases from the rest of South Asia, The Middle East and Africa.

Besides running their own highly successful programme, he and his team are also responsible for training most of the remaining liver transplant teams in India and neighbouring countries that have recently started performing this procedure. In disseminating expertise countrywide and beyond, building confidence in the procedure among patients and their referring physicians, and in moving it from experimental status to a highly successful life-saving procedure, he has in the true sense, pioneered the development of this speciality in India and the subcontinent in the last 15 years.

In his extensive experience of 21 years as a Liver Transplant Surgeon and Hepatobiliary surgeon, he has performed more than 1500 liver transplants and more than 12000 other complex liver, gall bladder and bile duct surgeries.

Dr Soin serves on the committees of all the important National and International Societies, as well as the National Advisory Board in Liver Transplantation. He is a regular Faculty member and speaker (often the only one from India) at most world fora in Liver Transplantation such as ILTS, AASLD, APDW, IHPBA, IASGO, APASL, Asian Living Donor Liver Transplant Group, Asia Pacific Organ Transplant Forum etc.

Snapshot of his academic Career:

Doctor Soin's initial surgical training was at the All India Institute of Medical Sciences(AIIMS), New Delhi. He spent 11 years there gaining his MBBS and MS degrees followed by specialist experience in Liver and Gastrointestinal Surgery, during which he published a researchthesisonPortal Hypertensive Gastropathy.

He then obtainedFRCSdegrees from both Glasgow and Edinburgh in the UK, following which he trained and worked at two of the world’s most renowned centers(University of Cambridge 5 years, University of Birmingham 1 year)for Liver and Biliary Surgery, and Liver, Kidney, Small Bowel and Pancreas transplantation for 6 years. He was one of the first few surgeons in the UK to qualify for and obtain an Intercollegiate FRCS in Transplant Surgery.

In addition to performing hundreds of transplants, he wasSurgical Tutor for the University of Cambridge, andFaculty for 2 of the Royal Colleges in Surgery. At Cambridge, he also conductedpioneering researchin transplantation. More than110 of his original research papers and book contributionshave been published / in international / national journals and books.

He was aVisiting Fellowat the Kyoto University Hospital in 1997 and Asan Medical Centre,Seoul, in 2000. He wasVisiting Facultyat the Ege University, Izmir, Turkey in 2004, and Istanbul in 2006 and 2007. These centres are among the world’s most renowned for living donor liver transplantation.

In the beginning of 1998, he gave up the opportunity of a Faculty post at University of Cambridge and chose to return to India to establish a centre of excellence in liver transplantation in his own coutry.Services/Interest

1. Awarded Padma Shri by the President of India in 2010 for pioneering the development of Liver Transplantation in India.2. Awarded the RD Birla Outstanding Clinician of the Year Award for the year 20103. Awarded the Zee TV - Swasth Bharat Samman Award for pioneering Liver Transplantation, 20114. Medical Statesman of the Year – e-MEDINEWS AWARDS, 20125. MSOSA Award for Excellence, 2014